Complications of the postpartum period
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Complications of the Postpartum Period. Hemmorhage. Early postpartum hemmorhage >500 ml in first 24 hrs (blood loss often underestimated) Late or delayed >500 cc after first 24 hrs. Predisposing factors. Uterine overdistension--large infant,etc. Grand multiparity Anesthesia or MgSO 4

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Complications of the Postpartum Period

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Complications of the postpartum period

Complications of the Postpartum Period


Hemmorhage

Hemmorhage

  • Early postpartum hemmorhage

    • >500 ml in first 24 hrs (blood loss often underestimated)

  • Late or delayed

    • >500 cc after first 24 hrs.


Predisposing factors

Predisposing factors

  • Uterine overdistension--large infant,etc.

  • Grand multiparity

  • Anesthesia or MgSO4

  • Trauma

  • Abnormal labor pattern--hypo or hypertonia

  • Oxytocin during labor

  • Prolonged labor

  • Hx of maternal anemia, hemorrhage


Prevention

Prevention

  • Risk assessment

  • Inspect placenta

  • Explore uterus

  • Avoid overmanipulation of uterus

  • If at risk type and Xmatch and start IV


Signs of impending hemorrhage

Signs of Impending Hemorrhage

  • Excessive bleeding (>2pads/30min-1hr)

  • Light headedness, nausea, visual disturbances

  • Anxiety, pale/ashen color, clammy skin

  • Increasing P and R, BP same or lower


Actions to take

Actions to take

  • Summon help

  • Check uterine tone, massage, assess effect

  • Elevate legs, lower head

  • Increase or begin O2

  • Increase or begin IV


Early postpartum hemorrhage

Early Postpartum Hemorrhage

Within the first 24 hrs

  • Causes

    • uterine atony

    • lacerations

    • retained secundines

    • coagulation problems


Uterine atony

Uterine atony

Failure of the uterus to stay firmly contracted

  • Slow, steady or massive hemorrhage, sometimes underestimated or hidden behind a clot

  • VS may not change immediately

    Treatment

  • bimanual massage

  • oxytoxics

  • curretage

  • surgery iliac ligation or hysterectomy


Retained placenta or fragments

Retained placenta or fragments

Partial separation caused by:

  • pulling on the cord

  • uterine massage prior to separation

  • placenta accreta

    Treatment:

  • massage

  • manual removal

  • oxytoxics

  • D & E


Late postpartum hemorrhage

Hemorrhage occurring after 24 hrs

retained placenta--necrosed, fibrin deposits, placental polyps, sloughingbleeding

Symptoms

excessive or bright red bleeding

boggy fundus

large clots

backache

T-P-R, BP

Late postpartum hemorrhage

Treatment, massage, IV oxytocin, D&E


Hematomas

Hematomas

Result from injury to a blood vessel, usually in vagina or vulva, may extend upward into broad ligament or other pelvic structures

  • develop rapidly

  • may contain 300-500ml blood


Symptoms

Symptoms

  • Severe pain

  • Difficulty voiding

  • Mass felt on vaginal exam

  • Flank pain

  • Abdominal distension

  • Shock


Treatment

Treatment

  • Ice

  • I & D (incision and drainage)

  • Packing


Subinvolution

Subinvolution

Uterus remains large, does not involute

Causes, retained placental fragments, infection

Symptoms:

  • Lochia fails to progress

  • Returns to rubra

  • Leukorrhea with backache and infection

    Treatment:

  • methergine

  • curretage

  • antibiotics


Puerperal infection

Puerperal Infection

Definition:

Temp of 101o or more in the first 24 hrs following delivery

Temp of 1004 or higher on any 2 of the first10 pp days (with the exception of the first 24 hrs)


Types of infections

Types of Infections

  • Endometritis

  • Parametritis

  • Peritonitis

  • Pyelonephritis

  • Cystitis

  • Thrombophlebitis

  • Mastitis, abcess


Predisposing factors1

Predisposing Factors

Antenatal factors

  • poor nutrition

  • low SES

  • Hx of Infections

  • Anemia

  • Immunodeficiency


Intrapartum predisposing factors

Intrapartum predisposing factors

  • Prolonged labor

  • PROM

  • Poor aseptic technique

  • Birth trauma

  • Multiple exams

  • Internal monitoring

  • Episiotomy

  • C section


Postpartum predisposing factors

Postpartum Predisposing Factors

  • Manual removal of placenta

  • Hemorrhage

  • Retained secundines


Causative organisms

Aerobic 30%

B hemolitc strep

E.coli

Klebsiella

Proteus

Pseudomonas

Staph

Anerobic 70%

Bacteriodes

Peptococcus

C. perfringes

Causative Organisms


Localized

Localized

  • Episiotomy

  • Lacerations

  • C section incision


Endometritis

Endometritis

Infection of the endometrium

  • placental site

  • decidua

  • cervix

    Symptoms--discharge (scant to profuse), bloody, foul smelling

    uterine tenderness

    jagged, irregular temp elevations

    tachycardia, chills, subinvolution


Salpingitis oopheritis

Salpingitis, Oopheritis

May be caused by gonorrhea, chlamidia

  • unilateral or bilateral abd pain

  • chills, fever

  • mass

  • tachycardia

  • may lead to sterility


Pelvic cellulitis parametritis

Pelvic Cellulitis, (parametritis)

Infection of the connective tissue of pelvis

  • frequently infecting the broad ligament and causing severe pain.

  • May ascend from cervical lacerations


Parametritis symptoms

Parametritis symptoms

  • Spiking temp to 104

  • chills, flushing, sweating

  • tachycardia, tachypnea

  • uterine tenderness, cramping

  • change in LOC/agitation,delerium, disorientation

  • change in lochia

  • cervical or uterine tenderness on vag exam

  • WBC elevation


Peritonitis

Peritonitis

Life threatening infection of the peritoneum

  • Abcesses on the uterine ligaments, in the cul de sac, and/or in the subdiaphragmatic space

  • May result from pelvic thrombophlebitis


Symptoms of peritonitis

High temp

chills

malaise

lethargy

pain

subinvolution

Tachycardia

local or referred pain

rebound tenderness

thirst

distension

nausea and vomiting

Symptoms of Peritonitis


Cystitis

Cystitis

Bladder infection

  • urgency

  • frequency

  • burning

  • dysuria

  • suprapubic pain

  • hematuria


Pyelonephritis

Pyelonephritis

Kidney infection, usually of the R. kidney.Ascends from bladder.

  • Spiking temp

  • Shaking chills

  • Flank pain, CVA pain

  • Nausea and vomiting

  • Hx of asymptomatic bacteruria or pyelonephritis

  • Urgency, frequency, dysuria

  • Back pain


Prevention and treatment

Prevention and treatment

  • Force fluids

  • Insure complete emptying of bladder

  • Sterile technique for cath

  • Good perineal care

  • Antibiotics


Thrombophlebitis blood clot associated with bacterial infection

Thrombophlebitis Blood clot associated with bacterial infection

Etiologies

  •  blood clotting factors

  • postpartal thrombocytosis (platelets)

  • thromboplastin release (placenta, amnion)

  • fibrinolysin and fibrinogen inhibitors


Superficial

Tenderness

heat

redness

low grade fever

+ homans sign

tachycardia

Treatment

elevation

heat

TEDs

analgesic

bedrest?

Antibiotics?

Superficial


Deep vein thrombosis

Symptoms

edema

low grade fever

chills

pain in limb below affected area

“milk leg”

decreased peripheral pulses

Dx--doppler

Tx:

heparin to coumadin

antibiotics

TEDs

bedrest

elevation

analgesics

Deep Vein Thrombosis


Pulmonary embolism an obstetrical emergency

Symptoms--sudden onset

dyspnea

sweating

pallor

cyanosis

confusion

hypertension

cough/hemoptysis

Tachycardia

SOB

 Temp

 jugular pressur

chest pain

sense of impending death

pressure in bowel/rectum

Pulmonary Embolisman Obstetrical emergency


Treatment1

Treatment

  • Call MD

  • O2

  • Demerol

  • Papaverine or other “clot busters”

  • Aminophylline

  • heparin

  • Streptokinase


Disseminated intravascular coagulation dic

Disseminated Intravascular Coagulation (DIC)

  •  prothrombin and platelets

  • widespread formation of intravascular clots

  • clotting factor expended

  • severe generalized hemorrhaging

    Life threatening!


Etiologies

Etiologies

  • Septic shock

  • placental/uterine hemmorhage

  • IUFD

  • Amniotic fluid embolism

  • thrombi secondary to preeclampsia

  • thrombi secondary to thrombophlebitis


Early signs of dic

Early signs of DIC

  •  protime

  •  fibrinogen

  • thrombocytopenia

  • bleeding from gums

  • bleeding from puncture sites

  • ecchymosis

    Treatment complex, packed cells, fibrinogen, whole blood, plasma


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